Shared decision making is a collaborative decision-making process between health care providers and patients or their surrogates, taking into account the best scientific evidence available while considering the patient's values, goals, and preferences. Decision aids are tools enabling SDM. This article discusses shared decision making in general and in the intensive care unit in particular and facilitators and barriers for the creation and implementation of International Patient Decision Aids Standards Collaboration-compliant decision aids for the intensive care unit and neuro-intensive care unit...

Infectious complications in the neurointensive care unit (neuro-ICU) are common, including pneumonia, urinary tract infection, bloodstream infection, and intracranial infection. The neuro-ICU population poses a specific challenge in the diagnosis of infections, because of the high incidence of fever in acutely brain-injured patients. Furthermore, susceptibility to infections is likely enhanced by brain-injury (induced immune modulation). This article reviews the concept of brain injury-induced immune modulation, and summarizes available data and knowledge on nosocomial meningitis and ventriculitis, and systemic infectious complications in patients with traumatic brain injury, ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and status epilepticus...

Acute cardiac complications in critical brain disease should be understood as a clinical condition representing an intense brain-heart crosstalk and might mimic ischemic heart disease. Two main entities (neurogenic stunned myocardium [NSM] and stress cardiomyopathy) have been better characterized in the neurocritically ill patients and they portend worse clinical outcomes in these cases. The pathophysiology of NSM remains elusive. However, significant progress has been made on the early identification of neurocardiac compromise following acute critical brain disease...

Status epilepticus (SE) is a medical emergency and presents with either a continuous prolonged seizure or multiple seizures without full recovery of consciousness in between them. The goals of treatment are prompt recognition, early seizure termination, and simultaneous evaluation for any potentially treatable cause. Improved understanding of the pathophysiology has led to a more practical definition. New data have emerged regarding the safety and efficacy of alternative agents, which are increasingly used in the management of these patients...

Primary intracerebral hemorrhage (ICH) is a common, devastating disease that lacks an effective specific treatment. Mortality is high, functional outcomes are poor, and these have not substantially changed for decades. There is, therefore, considerable opportunity for advancement in the management of ICH. In recent years, a significant amount of research has begun to address this gap. This article is aimed at updating neurologists on the most clinically relevant contemporary research.

Optimizing outcomes after aneurysmal subarachnoid hemorrhage remains a challenge for neurosurgeons and neurointensivists alike. Although we have learned a lot about the pathophysiology of this disease, many clinical questions are still unanswered. In this review, the authors discuss some of these questions, including the current diagnostic value of lumbar puncture in patients with negative computed tomography scans, the treatment value of blood pressure reduction and antifibrinolytics for prevention of early rebleeding, the indication for antiseizure medications, the optimal management of hydrocephalus and intracranial pressure, the role of clipping, and the options for diagnosis and treatment of delayed cerebral ischemia...

Evidence from animal models indicates that lowering temperature by a few degrees can produce substantial neuroprotection. In humans, hypothermia has been found to be neuroprotective with a significant impact on mortality and long-term functional outcome only in cardiac arrest and neonatal hypoxic-ischemic encephalopathy. Clinical trials have explored the potential role of maintaining normothermia and treating fever in critically ill brain injured patients. This review concentrates on basic concepts to understand the physiologic interactions of thermoregulation, effects of thermal modulation in critically ill patients, proposed mechanisms of action of temperature modulation, and practical aspects of targeted temperature management...

Spreading depolarization in cerebral cortex is associated with swelling of neurons, distortion of dendritic spines, massive ion translocation with a large change of the slow electrical potential, and silencing of brain electrical activity. The term spreading depression represents a wave of spontaneous activity of the electrocorticogram that propagates through contiguous cerebral gray matter at a characteristic velocity. Spreading depression is a consequence of cortical spreading depolarization. Therefore, spreading depolarization is not always accompanied by spreading depression and the terms are not synonymous...

The care of patients with traumatic brain injury can be one of the most challenging and rewarding aspects of clinical neurocritical care. This article reviews the approach to unique aspects specific to the care of this patient population. These aspects include appropriate use of sedation and analgesia, and the principles and the clinical use of intracranial monitors. Common clinical challenges encountered in these patients are also discussed, including the treatment of intracranial hypertension, temperature management, and control of sympathetic hyperactivity...

Monitoring intracranial pressure in comatose patients with severe traumatic brain injury (TBI) is considered necessary by most experts. Acute intracranial hypertension (IHT), when severe and sustained, is a life-threatening complication that demands emergency treatment. Yet, secondary anoxic-ischemic injury after brain trauma can occur in the absence of IHT. In such cases, adding other monitoring modalities can alert clinicians when the patient is in a state of energy failure. This article reviews the mechanisms, diagnosis, and treatment of IHT and brain hypoxia after TBI, emphasizing the need to develop a physiologically integrative approach to the management of these complex situations...

Stand-alone cervical laminectomy for degenerative cervical myelopathy (DCM) has become increasingly rare due to risk of postlaminectomy kyphosis. This article discusses the biomechanics of cervical degeneration and how laminectomy effects spine stability, and summarizes relevant clinical studies to help guide surgical decision-making for the posterior treatment of DCM. Laminectomy and fusion remains a safe and efficacious treatment. Stand-alone laminectomy should only be used for a highly selected patient population with relative stiff lordotic cervical spines, using care to not disrupt facets and C2 and C7 muscle attachments...

Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in the world. There are multiple types of anterior approaches for treating patients with DCM. Many strategies have been developed to reduce complications for multilevel anterior surgery. Posterior approaches are sometimes used to supplement more extensive anterior approaches. More recently, multilevel cervical arthroplasty has been used for this condition. More data soon will be available comparing anterior and posterior approaches with the goal of optimizing patient-related quality of life and reducing complications, which include dysphagia, weakness, and instrumentation failure in some cases...

Cervical spine sagittal malalignment correlates with worse symptoms and outcomes in patients with degenerative cervical myelopathy (DCM), and should influence surgical management. An anterior versus posterior surgical approach may not significantly change outcomes in patients with preoperative lordosis; however, most studies suggest improved neurologic recovery among kyphotic patients after adequate correction of local sagittal alignment through an anterior or combined anterior-posterior approach. There are no comprehensive guidelines for DCM management in the setting of cervical malalignment; therefore, surgical management should be tailored to individual patients and decisions made at the discretion of treating surgeons with attention to basic principles...

Ossification of the posterior longitudinal ligament (OPLL), ossification of the anterior longitudinal ligament (OALL), and ossification of the ligamentum flavum (OLF) sometimes are seen in the same patients, but the exact coexisting frequencies are not clear especially in the cervical region. The most frequent combination is OPLL and OALL. Cervical OPLL can coexist with thoracic OLF but is rarely associated with cervical OLF. All of these ossifying diseases of the cervical spinal ligaments are influenced by dynamic factors of the spinal column...

There are 3 basic radiological patterns of dural ossification (DO). Although double-layer DO is most common, when examining neuroimaging of ossification of the posterior longitudinal ligament (OPLL), isolated DO or masse DO should be kept in mind. Bone window computed tomography (CT) is most sufficient in identifying any type of DO associated with OPLL. Sagittal reformation of CT has replaced polytomography. MRI is not optimal for identification of DO and OPLL. Surgical approaches should be determined based on this important radiological information to avoid an unexpected complication...

Calcification of the ligamentum flavum (CLF) and ossification of the ligamentum flavum (OLF) in the cervical spine are differential diagnoses in patients with posterior extradural compressive lesions related to cervical degenerative disease. Preoperative computed tomography can facilitate the detection of characteristic findings and help to distinguish between CLF and OLF. Although these are rare entities in the cervical spine, adequately timed surgical decompression is required in most patients who present with radiculomyelopathy...

Degenerative cervical myelopathy (DCM) is a common neurologic condition that is often treated with surgery. Imaging plays a central role in the management of DCM, including diagnosis, preoperative planning, postoperative assessment, and prognostication. Radiographs, CT, and MRI offer unique and complementary assessments, and all have important uses in current clinical practice. Emerging microstructural and functional MRI techniques have the potential to have a major impact, potentially transforming practice by offering earlier and more accurate diagnosis, monitoring for deterioration, and prediction of outcomes...

Despite being the leading cause of spinal cord dysfunction among adults worldwide, little is known about the natural history of degenerative cervical myelopathy (DCM). There is mounting evidence of the effectiveness of surgery for DCM in halting progression of symptoms, and in fact, in improving neurologic outcomes, functional status, and quality of life. However, surgical decision making relies on a weighing of the risks and benefits of alternative strategies. We reviewed the available literature pertaining to the natural course of DCM and the predictors of outcome of nonoperative approaches...